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Implantation bleeding
Non gestational
Miscarriage
Ectopic pregnancy
Hydatidiform molar pregnancy
MISCARRIAGE
DEFINITION:
THE EXPULSION OF THE PRODUCTS OF
CONCEPTION FROM THE UTERUS
BEFORE THE 28TH WEEK OF GESTATION
MISCARRIAGE
SPONTANEOUS
INDUCED
ETIOLOGY OF MISCARRIAGES
Fetal chromosomal abnormality
Trisomies 13, 18, 21
Triploidies and tetraploidies
Monosomy X (Turners syndrome)
Translocation (hereditary)
Uterine abnormalities
Congenital: Septate uterus, uni/bicornuate
uterus
Acquired: intrauterine adhesion, fibroids,
retroverted uterus
ETIOLOGY OF MISCARRIAGES
Cervical incompetence
Congenital: deficiency of connective tissue
Acquired: previous cervical laceration, previous
overzealous dilation of the cervix
Maternal infections
Antiphospholipid Syndrome
ETIOLOGY OF MISCARRIAGES
OTHER:
Cigarette smoking
Cocaine increased risk of miscarriage
Alcohol - higher in women ended up with
miscarriage
Caffeine high level ass. with miscarriage
Chemicals : lead, ethylene oxide, solvents,
pesticides, vinyl chloride & anesthetic gases
ass. with fetal loss
Radiotherapy & Chemotherapy
CASE 1
A 26 yr old nulliparous woman presented with
8 weeks of amenorrhea. She has not been using
any contraception and normally has a regular
menstrual cycle every 28 days.
A pregnancy test was positive and she is
approximately 6 weeks pregnant.
However, today she noticed vaginal bleeding.
2.
3.
4.
5.
2.
3.
4.
2.
3.
4.
MANAGEMENT OF EARLY
PREGNANCY FAILURE
1.
2.
3.
EXPECTANT MANAGEMENT
MEDICAL MANAGEMENT
Drugs that stimulates rhythmic contractions of the
uterus, increases the frequency of existing
contractions, and raises the tone of the uterine
musculature
1. Syntocinon, syntometrine (synthetic form of
oxytocin)
2. Misoprostol (syntheticPGE1) causes uterine
contraction and ripening of the cervix
3. Mifeprostone (synthetic steroid compound) that
antagonizes progesterone
SURGICAL MANAGEMENT
Dilatation and curettage
The woman is usually put undergeneral
anesthesiabefore the procedure begins.
A curette, a metal rod with a handle on one end
and a sharp loop on the other, is inserted into the
uterus through the dilated cervix.
The curette is used to gently scrape the lining of
the uterus and remove the tissue in the uterus.
This tissue is examined for completeness
SURGICAL MANAGEMENT
Evacuation of retained products of
conception
Instead of a curette, a cannula is inserted into
the uterus for the extraction of the fetus. The
cannula has a tube attached to it that leads to a
bottle and a pump that acts as a gentle vacuum.
After the cannula has been removed, a pair of
forceps is inserted to remove any remaining
tissue. A curette is used for this as well to scrape
the lining for any remaining traces of the fetus.
And, then, the womb is vacuumed out again just
to make sure the job was done properly.
SURGICAL MANAGEMENT
Indications for Surgical uterine evacuation :
1.
2.
3.
4.
5.
Patients preference
Persistent excessive bleeding
Haemodynamic instability
Evidence of infected retained tissue
Suspected gestational trophoblastic disease
SURGICAL MANAGEMENT
COMPLICATIONS :
1. Cervical incompetence
2. Perforation of the uterus
3. Ashermans syndrome
4. Anesthetic complication
5. Urinary retention
6. Hemorrhage
7. Pelvic pain/ infection
8. Scarring
THREATENED MISCARRIAGE
Pain: Variable, possibly slight lower abdominal
pain or backache
Bleeding: Scant, during first 3 months
Cervical Os: Closed, no dilation
Uterus: If palpable, soft and not tender
RX OF THREATENED MISCARRIAGE
Bed rest
Avoidance of coitus
Assessment for whether patient is a candidate for
progesterone supplements
Depro- provera to reduce uterine contractions
Reassurance and psychological support
recommended
INEVITABLE MISCARRIAGE
Pain: Severe, rhythmical
Bleeding: Heavy, clots
Cervical Os: Open with dilation
Uterus: If palpable, smaller than expected
INEVITABLE MISCARRIAGE
Occasionally severe shock may be due to
massive haemorrhage / vasovagal reaction
cervical shock syndrome due to distension of the
cervix by POC
Oxytocic drug may be given such as syntocinon
infusion
Evacuation of uterus maybe be required if the
miscarriage is incomplete
INCOMPLETE MISCARRIAGE
Pain: Severe
Bleeding: Heavy, profuse
Cervical Os: Open with dilation
Uterus: Tender and painful
Other: Tissue present in cervix
INCOMPLETE MISCARRIAGE
Evacuation of retained products of conception
from the uterus carried out
Medical management possible using
prostaglandin analogues such as misoprostol or
mifeprostone and synthetic oxytocinsyntometrine to maintain contractions
If surgical evacuation required, woman should be
screened for chlamydial infection
Transfusion may be given if blood loss excessive
COMPLETE MISCARRIAGE
Pain: Diminishing or absent
Bleeding: Minimal or absent
Cervical Os: Closed
Uterus: If palpable, firm and contracted
MISSED MISCARRIAGE
Bleeding between uterine wall and gestational sac
occurs and intrauterine fetal death occurs before 28th
week of pregnancy resulting in the formation of a
carneous mole or there is formation of a blighted
ovum
Pain: Absent
Bleeding: Some spotting possible, brown colour
Cervical Os: Closed
Uterus: If palpable, smaller than expected
Ultrasound: no fetal movement, heart sounds, small
for dates
RX OF MISSED MISCARRIAGE
SEPTIC MISCARRIAGE
Pain: Severe or variable
Bleeding: Variable, may be offensive
Cervical Os: Open
Uterus: Bulky, tender and painful on
examination
Other: fever, tachycardia, headache, nausea and
general malaise, purulent vaginal discharge
SEPTIC MISCARRIAGE
Causitive organisms:
E. coli
Proteus
Klebsiella
Clostridium Welchii
Clostridium perfingens
High vaginal swab and blood cultures should be
taken
Risks include septicaemia, endotoxic shock, DIC,
liver and renal damage, salpingitis and infertility
RX OF SEPTIC MISCARRIAGE
Mild/uncomplicated- no Hx of shock, peritonitis
temp <100F
1.
2.
3.
4.
RX OF SEPTIC MISCARRIAGE
Sever- shock, generalized peritonitis, temp >100F,
hypotension, bladder and bowel injury, oliguria
1.
2.
3.
4.
POA
PV
POC
BLEED
AB
CERVICAL
UTERINE
PAIN
OS
SIZE
DIAGNOSIS
Nil/+
Closed
= dates
THREATENED
Spotdark
brown
Minim
al
Closed
< dates
MISSED
Open
= dates
INEVITABLE
Open
< dates
INCOMPLETE
+++
Closed
< dates
COMPLETE
Closed
< dates
ECTOPIC
Vesice
ls
Open
> Dates
(50%)
25%= dates
25< dates
MOLE
CASE 2
A 32-year-old patient, Para 0+4 is referred to the
antenatal clinic after presenting with amenorrhea
for the last 10 weeks and positive urine pregnancy
test. Her last 4 pregnancies have ended
spontaneously at 18 to 20 weeks.
RECURRENT OR HABITUAL
MISCARRIAGES
Definition: loss of 3 consecutive pregnancies
Etiology:
Genetic abnormalities
Uterine anomalies
Uterine fibroids
Cervical incompetence
Polycystic Ovarian syndrome, insulin resistance
and hyperprolactinaemia
Anti phospholipid syndrome
RX RECURRENT OR HABITUAL
MISCARRIAGES
Anti phospholipid syndrome:
HEPARIN
low dose ASPIRIN
IVIG and prednisolone
PCOS: metformin
Cervical incompetence: cervical cerclage (14 to 16 th
week) Shirodkar technique
Mc Donald stitch
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